Superficial keratectomy and conjunctival autograft for Fuchs' superficial marginal keratitis.

PURPOSE: To describe a patient with bilateral, recurrent marginal corneal infiltrates consistent with Fuchs' superficial marginal keratitis who developed bilateral nasal pseudopterygia encroaching on the visual axis, reducing visual acuity in both eyes. METHODS: Bilateral superficial keratectomy combined with conjunctival autografting was performed in each eye. RESULTS: Best corrected visual acuity improved from 20/60 in the left eye and 20/40 in the right eye to 20/25 in both eyes. Our patient has had no disease relapses in her right eye, as of 29 months after the surgery, but experienced a mild flare-up of marginal keratitis in her left eye 8 months after the surgery. Despite this flare-up, disease symptoms in the left eye have markedly diminished. CONCLUSION: Superficial keratectomy combined with conjunctival autograft is a therapeutic alternative in the management of severe, recurrent Fuchs' superficial marginal keratitis. In the present case, it has resulted in an improvement in visual acuity as well as a decrease in the frequency of disease flare-ups. The clinical course of this patient suggests that the conjunctiva may play a role in the etiology of Fuchs' superficial marginal keratitis.

Congenital corneal opacification in De Barsy syndrome.

A newborn male was noted to have bilateral congenital corneal opacification. Findings from examination disclosed a variety of dysmorphic features, including cutis laxa, progeroid aspect, short stature, multiple hyperextensible subluxated joints, muscular hypotonia, and hyperreflexia. Bilateral penetrating keratoplasties were performed; histopathologic examination revealed diffuse epithelial thickening, loss of the Bowman layer, and stromal attenuation with anterior stromal scarring. Special stains showed no deposition of abnormal material in the corneas. Electron microscopy demonstrated absence of Bowman layer differentiation with a paucity of collagen fibers, as well as extensive small elastic fibers in the anterior stroma. The diagnosis of De Barsy syndrome was made, a rare progeroid syndrome associated with characteristic ocular, facial, skeletal, dermatologic, and neurologic abnormalities. De Barsy syndrome should be included in the differential diagnosis of congenital corneal opacification; its distinctive clinical features enable the clinician to easily differentiate it from other causes of congenitally cloudy corneas.

Phototherapeutic keratectomy for Schnyder's crystalline corneal dystrophy.

PURPOSE: To describe the treatment of Schnyder's crystalline dystrophy (SCD) with excimer laser phototherapeutic keratectomy (PTK). METHODS: Chart review of three patients (four eyes) with SCD treated with PTK between March 1992 and December 1998. Pre- and posttreatment visual acuity, subjective glare, photophobia, manifest refraction, ultrasound pachymetry, hyperopic shift, and biomicroscopic findings were studied. Brightness acuity testing (BAT) was evaluated in two eyes. RESULTS: Four eyes were treated during the study period. The average best corrected visual acuity (BCVA) improved from 20/175 to 20/40 under bright conditions. All patients reported subjective improvement in glare and photophobia. No visually significant recurrence was observed during the follow-up period which ranged from seven months to three years. The mean spherical equivalent refractive shift was +3.28 diopter (D). One patient developed irregular astigmatism from an eccentric ablation. No vision threatening complications were observed. CONCLUSION: PTK can be effective at improving visual symptoms in patients with SCD. It can be a useful therapeutic alternative to lamellar or penetrating keratoplasty in these patients.

Management of primary corneal graft failure.

PURPOSE: We report two patients with primary graft failure (PGF) from a mutual donor. The surgery in each case was done by a different surgeon experienced in penetrating keratoplasty (PK). The cases were managed differently in the postoperative period with good visual results in both cases. We discuss the various management options available when confronted with apparent PGF in the early postoperative period. METHODS: Both patients had excessive graft edema and haze in the immediate postoperative period. Case 1 received a repeat graft after 4 weeks because there was no improvement in graft clarity despite intensive topical steroids. In case 2, repeat surgery was deferred with ultimate gradual improvement in the clarity of the graft over a period of 6 months. RESULTS: Both patients obtained clear grafts with a visual acuity of 20/30 at 15 months after surgery. CONCLUSION: Primary graft failure is a rare complication of PK. Repeat PK is the most definitive therapeutic alternative, although some grafts may clear without any additional surgery. We suggest all cases of PGF be observed for > or = 3-4 weeks for signs of graft clearing before proceeding with a repeated PK.

Indications for penetrating keratoplasty and associated procedures, 1989-1995.

PURPOSE: To identify changing trends in indications for penetrating keratoplasty and associated surgical procedures. METHODS: Review of charts from all patients who underwent penetrating keratoplasty at Wills Eye Hospital from January 1, 1989 through December 31, 1995. RESULTS: A total of 2,442 corneal transplants were performed in 2,186 patients. The leading indication for penetrating keratoplasty was pseudophakic corneal edema, accounting for 634 cases (26.0%); 54.7% of them were associated with anterior chamber intraocular lenses, 36.4% with posterior chamber intraocular lenses, and 3.1% with iris-fixated intraocular lenses. Regraft (17.8%), Fuchs' dystrophy (15.7%), and keratoconus (13.2%) followed pseudophakic corneal edema in frequency. Cataract extraction, with or without intraocular lens implantation, was combined with penetrating keratoplasty in 439 cases of 1,264 phakic eyes (34.7%). Intraocular lens exchange was performed in 285 of the 634 cases of pseudophakic corneal edema (44.9%). CONCLUSION: Pseudophakic corneal edema was the leading indication for penetrating keratoplasty, with an increasing number of cases associated with posterior chamber intraocular lenses during the study period (p = 0.001). The number of regrafts steadily increased between 1989 and 1995 (p = 0.001), being the second most common indication for corneal transplantation since 1992.

Infantile ulcerative keratitis secondary to congenital entropion.

Congenital entropion is a rare eyelid anomaly that can cause chronic corneal erosions or ulceration. The diagnosis may be easily overlooked by both the pediatrician and the ophthalmologist, particularly when the lids are tightly closed in the crying child. We present three cases of congenital entropion associated with corneal ulceration. Each patient underwent a complete ophthalmologic examination. Examination under anesthesia, including corneal scrapings for culture and photography, was performed before surgical repair of the entropion. There were two cases of lower lid entropion and one case of upper lid entropion. In all three cases symptoms were present since birth, and the diagnosis was overlooked by the treating pediatrician. Corneal ulceration ultimately developed in all three cases. Cultures revealed Staphylococcus aureus in one case, and coagulase negative Staphylococcus in another case. Cultures were negative in one case. In all three patients the ulcers healed rapidly after surgical entropion repair. Congenital upper or lower lid entropion is an uncommon condition that does not spontaneously improve and is an important cause of corneal ulceration in infants. Recognition of this condition is often difficult, and early surgical intervention to repair the lid deformity may help to avoid permanent corneal scarring and visual loss.

Repair of Descemet's membrane detachment with intracameral injection of 20% sulfur hexafluoride gas.

Detachment of Descemet's membrane is a rare complication of cataract surgery that can cause permanent corneal decompensation. We report five patients with Descemet's membrane detachments who were successfully treated with intracameral injection of 20% sulfur hexafluoride gas with resultant resolution of their corneal edema.

Superior limbic keratoconjunctivitis in association with scarring of the superior tarsal conjunctiva.

Three patients are reported with clinical findings compatible with a diagnosis of superior limbic keratoconjunctivitis (SLK) that developed in association with scarring of the palpebral conjunctiva. Although the etiology of SLK is unknown, these patients support the theory of a mechanical cause for SLK.

Results of alloplastic tube shunt procedures before, during, or after penetrating keratoplasty.

The association of glaucoma and penetrating keratoplasty presents a difficult management problem, particularly when medical therapy and conventional glaucoma surgery have failed. We have found alloplastic tube shunt surgery to be an effective method for intraocular pressure control in glaucomatous eyes subjected to penetrating keratoplasty. We report 46 patients who underwent alloplastic tube shunt implantation before (13 patients, group A), in combination with (17 patients, group B), or after (16 patients, group C) penetrating keratoplasty. All groups had significantly lowered intraocular pressure postoperatively. The most common complication was graft failure, in 31% of patients in group A, 29% in group B, and 44% in group C. Other postoperative complications and results including visual outcome are reviewed. Because the management of advanced glaucoma in patients undergoing keratoplasty is difficult, alloplastic tube shunt implantation should be considered.

Glaucoma associated with epithelial downgrowth controlled with Molteno tube shunts.

We report two histopathologically proven cases of epithelial downgrowth in which the secondary glaucoma was controlled by a double-plate Molteno tube shunt and useful vision restored with a penetrating keratoplasty. The combination of a tube shunt and penetrating keratoplasty may be indicated to maintain useful vision in advanced cases of epithelial downgrowth associated with secondary glaucoma.

Propionibacterium acnes endophthalmitis after intracapsular cataract extraction.

The authors report a case of Propionibacterium acnes endophthalmitis after intracapsular cataract extraction with implantation of an anterior chamber intraocular lens. The patient's chronic inflammation persisted for 5 years after cataract surgery despite treatment with pars plana vitrectomy, intraocular lens removal, topical and oral steroids, and topical fortified antibiotics. Fluctuations in the inflammation were paralleled by changes in the size and appearance of a white plaque on the posterior corneal surface. Anterior chamber tap cultures were positive for P. acnes after 8 days of incubation under anaerobic conditions. The inflammation was not controlled until the posterior corneal plaque, which was the presumed nidus of the chronic infection, was removed and the patient was treated with intravitreal and oral antibiotics.

Epithelial downgrowth following the removal of iris inclusion cysts.

We present three patients in whom epithelial downgrowth occurred following the excision of iris inclusion cysts. The sheet-like downgrowth was aggressively treated and successfully eradicated in two of the three patients. Early identification and prompt therapy are essential.

Keratoconus associated with corneal endothelial dystrophy.

Keratoconus is found in conjunction with many ocular and nonocular disorders. We describe five patients with concurrent keratoconus and corneal endothelial dystrophy.

Class II alloantigen induced on corneal endothelium. Role in corneal allograft rejection.

The expression of Class II major histocompatibility complex (MHC) antigens on corneal cells can be increased in vitro by (gamma-interferon) and in vivo in inflammatory reactions. The expression of Class II MHC by corneal endothelium of New Zealand White (NZW) rabbits during the rejection of corneal allografts was demonstrated by immunoperoxidase staining. Class II MHC expression by corneal endothelial cells may facilitate rejection of corneal allografts.

Hepatitis B surface antigen in corneal donors.

Using an enzyme immunoassay, we detected hepatitis B surface antigen in washings of ocular tissue from two of three corneal donors who had positive serum assays for hepatitis B surface antigen. Hepatitis B surface antigen was identified in emulsified corneal tissue from one of two donors from whom corneal tissue was available for study.

Acute band keratopathy following intracameral Viscoat.

Band keratopathy developed rapidly in two patients following uneventful phacoemulsification and intraocular lens implantation using BSS Plus (balanced salt solution enriched with glutathione, bicarbonate, and glucose) infusion and Viscoat (chondroitin sulfate-sodium hyaluronate), which was left in the anterior chamber at the conclusion of the procedure. Histopathologic evaluation of corneal tissue obtained from one patient at the time of edetic acid chelation revealed histochemical findings consistent with anterior stromal calcification. To investigate a possible relationship between Viscoat and the rapid onset of band keratopathy, Viscoat formulated with varying concentrations of phosphate buffer was injected intracamerally into 42 rabbit eyes. Within 48 hours, clinically obvious corneal opacification developed in nine (47%) of 19 eyes injected with the commercial preparation of Viscoat. Also, similar opacification developed in ten (77%) of 13 eyes that received Viscoat formulated with twice the phosphate concentration of the commercial preparation. Band keratopathy did not develop any of ten eyes that received Viscoat with one fourth the commercial phosphate concentration. In selected opacified corneas, the presence of phosphorus in the subepithelial and posterior corneal stroma was confirmed by histochemical stains and energy-dispersive x-ray analysis.